Epidemic dropsy 2013: case series

Studies on pharmacokinetic properties and intestinal absorption mechanism of sanguinarine chloride: in vivo and in situ

Sanguinarine (SAN) is an alkaloid with multiple biological activities, mainly extracted from Sanguinaria canadensis or Macleaya cordata. The low bioavailability of SAN limits its utilization. At present, the nature and mechanism of SAN intestinal absorption are still unclear. The pharmacokinetics, single-pass intestinal perfusion test (SPIP), and equilibrium solubility test of SAN in rats were studied. The absorption of SAN at 20, 40, and 80 mg/L in different intestinal segments was investigated, and verapamil hydrochloride (P-gp inhibitor), celecoxib (MPR2 inhibitor), and ko143 (BCRP inhibitor) were further used to determine the effect of efflux transporter proteins on SAN absorption. The equilibrium solubility of SAN in three buffer solutions (pH 1.2, 4.5 and 6.8) was investigated. The oral pharmacokinetic results in rats showed that SAN was rapidly absorbed (Tmax=0.5 h), widely distributed (Vz/F = 134 L/kg), rapidly metabolized (CL = 30 L/h/kg), and had bimodal phenomena. SPIP experiments showed that P-gp protein could significantly affect the effective permeability coefficient (Peff) and apparent absorption rate constant (Ka) of SAN. Equilibrium solubility test results show that SAN has the best solubility at pH 4.5. In conclusion, SAN is a substrate of P-gp, and its transport modes include efflux protein transport, passive transport and active transport.

Clinical Profile and Outcomes of Epidemic Dropsy Patients Attending a Tertiary Care Centre in Assam, India

Background The clinical condition of epidemic dropsy is caused by the consumption of edible oils contaminated with Argemone mexicana oil. Two of the most toxic alkaloids found in argemone oil are sanguinarine and dehydrosanguinarine, which cause capillary dilation, proliferation, and increased permeability. Extreme cardiac decompensation leading to congestive heart failure and glaucoma resulting in blindness are the most serious consequences of epidemic dropsy.  Materials and methods All patients attending the medicine department of Tezpur Medical College and Hospital with clinical features of epidemic dropsy were included in the study after obtaining informed consent. All patients, after a complete history, underwent a thorough clinical examination, and findings were recorded using a pre-formed proforma. Along with routine blood examination, patients were also evaluated with echocardiography, ECG, and chest X-ray. Cooking oil samples obtained from patients were investigated for the presence of sanguinarine in a standardized laboratory with the help of the district authority. The statistical analysis was done using MS Excel 2017. Results Out of 38 patients, 36 were male (94.7%), and only two were female (5.2%). Male to female ratio was 18:1. This difference in sex ratio may be due to the fact that only severely ill patients attended our tertiary care hospital. In contrast, moderate and mildly ill patients were treated in local hospitals. The mean age of patients was 28.1 years, and the mean length of hospital stay was eight days. Bilateral pitting type of ankle edema was the most common clinical manifestation, and all 38 patients (100%) exhibited edema. A total of 76% of patients had dermatological manifestations. Sixty-two percent of patients had gastrointestinal manifestations. In cardiovascular manifestation, persistent tachycardia was seen in 52% of patients, pansystolic murmur was best heard in the apical area in 42% of patients, and 21 percent had evidence of a raised jugular venous pressure (JVP). Five percent of patients had pleural effusion. Sixteen percent of patients had ophthalmological manifestations. Eight patients (21%) required ICU care. The in-hospital fatality rate was 10.53% (n=4). Of the expired patients, 100% were male. The most common cause of death was cardiogenic shock (75%), followed by septic shock (25%). Conclusion From our study, it was found that most of the patients were male, with an age group of 25-45 years. The most common clinical manifestation was dependent edema, along with signs of heart failure. Other common manifestations were dermatological and gastrointestinal. The severity and outcome were directly related to the delay in seeking medical consultation and diagnosis.